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Andra Striowski, Ocularist

I have been working as an ocularist since 2014.

Andra Striowski, Ocularist in her office where she makes prothetic eyes
Andra Striowski, Ocularist

· How did you learn this trade?

I met a seasoned ocularist who was running a successful practice in my city who told me he was “always looking for people who are good with color” to help him paint his eyes. I have a background in fine arts and used to work as a portrait painter, so he invited me to his clinic to try painting a few irises. Turns out I have an aptitude for matching the colors and accurately replicating the iris details, so I began my apprenticeship. In 2019 I passed my board certification exams, and I recently opened my own clinic in Toronto.

· What made you want to become an ocularist?

Ocularistry offers me a wonderful opportunity to apply my fine arts skills in a practical and functional way that helps other people. I know that some patients get frustrated with the slow, hand-made process but I love that I get to sit down and talk to the patient and learn about them as I paint their eyes. I get to meet interesting people from diverse walks of life, and I feel privileged to get to participate in their healing.

· What is something most people don’t know about ocularists?

It is usually handed down through generations! Ocularists are very proud of the legacy of their craft.

· What is the number one question most patients ask?

A lot of people ask me why I can’t just take a picture of the iris and print it onto the prosthesis.

· Do you have one patient, in particular, you will always remember? Why?

I have so many lovely patients that come to mind but one, in particular, had the most astounding life story: He was orphaned as a child during the civil war in Somalia, and one day he was playing with some other kids in a ditch when a landmine exploded, damaging his face and rendering him blind in one eye. With the help of some older kids, he traveled through the continent to South Africa, eventually catching a boat to Brazil, somehow making his way to Canada where he applied for and was granted refugee status. When I first met him he was only in his early twenties but I was in awe of him. I hope he writes a memoir someday.

· Can you walk us through the process of making a prosthetic eye?

First I do an assessment to determine if the patient can wear a prosthesis or is ready for a new one. If so, I will prepare an impression tray that suits the size and front curvature of their eye, and I will take an impression using a liquid plastic that molds itself to the contours of the cavity of the socket in about a minute. I then prepare an iris disk of the appropriate diameter and pupil size for the patient, and paint the color of the iris, matching it to their natural eye. The patient then takes a break or goes home while I cast the impression in plaster and I make an acrylic prototype to try at the next appointment. With the patient present again, the prototype is adjusted and refined in order to match the shape of the remaining eye, to make sure that there is no gapping at the edges, to determine the direction of the gaze, and to ensure that it is comfortable. Again the patient goes home and I return to the lab to build the eye out of the custom shape and iris. I used to bring the patient back to the clinic to be present for a third session where I paint the white veins of the eye, but as I have gotten more experienced I find I am able to do this part effectively from memory. So during the third and final session, the patient comes in to try in their completed prosthetic eye. From time to time a minor adjustment needs to be made but for the most part, this is where they go home happy with their new eye.

Behind the scenes of making eyes. pictures of every stage of the prosthetic eye process.
Behind the scenes of making eyes

· What is your least favorite thing about your profession?

I wish we were affiliated with universities so that we had better access to research tools – it is very hard to advance the profession without institutional support.

· What is your favorite thing about your profession?

That my patients bring my artwork to life.

· How many patients do you see in a year?

We used to see hundreds at the practice where I did my apprenticeship, but I am currently building a new practice from the ground up! I expect to have seen about 40 patients here by the end of my first year.

· How many different ways can you make a prosthetic eye?

I personally make eyes out of acrylic but my colleagues in Germany can also make them out of cryolite glass. Within the acrylic genre, there are currently a couple of different ways to cure the plastic (microwave or water bath) and there are some minor variations in painting technique, but overall we have pretty strict professional standards that we must adhere to, so there isn’t a huge amount of variation from one ocularist to the next. We are also on the cusp of introducing 3D scanning and printing into our workflow, but we don’t have regulatory approval for this in North America yet. (Note: I am writing a blog on the topic of the incoming digital tech for ocularists

· How long does the process take?

Since every eye is custom-made the time it takes can vary quite a bit from one case to the next, depending on the unique challenges of the socket and the types of surgeries the patient has had. In general, I book two, two-hour appointments for fitting and painting which is usually more than enough, and a thirty-minute appointment for pick up. In addition to this, I do about two hours of lab work between each appointment. So it usually takes about eight to ten hours in total.

· What age group do you tend to make eyes for the most?

I see patients of all ages, but most of my patients are older. There is such a diversity of causes for eye loss, so many of them freak accidents, and the longer one has lived the more opportunities one has had to lose an eye.

· How has the trade changed over the years? - process, paints, materials,

I would say that the trade has changed very little since WW2 when ocularists in North America first started making eyes out of plastic instead of glass. In about the 90’s most ocularists started using pressurized curing units which speed up the time it takes to process the plastic. Over the years there has been some experimentation with different ways of connecting the prosthesis to the implant to help it move better, but none of them really took off and most surgeons have gone back to using simple spherical implants.

The biggest change I’ve seen is in the attitudes of the prosthetic eye wearers themselves. It used to be that patients were made to feel ashamed that they were wearing a prosthesis and did everything they could to make sure no one knew they were missing an eye. But more and more I am seeing a new generation of patients who decide to embrace the fact that they wear a prosthetic eye and see it as an opportunity to play around with their look, which I love! I’ve had so much fun designing and making unique artistic eyes that patients choose to wear as decorative accessories or conversation pieces.

Custom Eagle Prothetic Eye- hand painted.
Custom Eagle Prothetic Eye

· Can you sleep in your prosthetic eye?

Yes, anyone who has had an enucleation or evisceration can and should leave their eye in the socket to sleep. Some people who are wearing a scleral shell over a blind eye prefer to take it out at night which is fine.

· What if someone doesn’t like their prosthetic eye can you make changes to it what would that look like?

Absolutely. I highly encourage my patients to speak up if there is anything they would like to see a little differently. The great thing about making the eyes by hand is that we have a lot of freedom to change the color or shape to suit the patient's wishes. When this happens usually the patient will come in for a follow-up where we discuss the desired changes, and they will leave the prosthesis with me to work on. Then they will pick it up later that day or at another time that is convenient. If it is within the first three months of receiving their eye all adjustments are complimentary.

· How often do you have unhappy patients? What are the most unhappy about?

I think when patients are unhappy it is for the most p

art because it can just be a really crappy experience to lose an eye. It’s hard to adjust to this new reality emotionally, especially when there is also damage to the lids and sockets that makes it impossible for us to achieve perfect symmetry with the shape. As ocularists, we all do our best and use every tool at our disposal to give our patients the best possible result, but sometimes our solutions involve tradeoffs: for instance, if you make the eye bigger to compensate for volume loss in the upper lid this also makes it heavier and can cause the bottom lid to droop. Telling the patient that they have to choose between two imperfect options is never fun and is understandably demoralizing. That is usually when I suggest getting an oculoplastic surgeon involved.

· How do most people adjust to getting a prosthetic eye early in life compared to people who are adults?

I think that at any age the most important factor that helps people adjust to living with a prosthetic eye is having supportive people around them. This is especially crucial for children but is important for adults too. With children, there is the added technical challenge of helping the bony orbit and soft tissues grow until they reach maturity, which means frequent fittings to update the size of their prosthesis and stimulate that growth on the anophthalmic side. What is remarkable to me is how well people of all ages are able to learn to perceive depth with one working eye: it is a neurological phenomenon that seems to take care of itself no matter what age, as long as the individual gets back out there engaging in life and doing the things they would do with two eyes (driving, sports, etc). The biggest obstacle to adjusting to life with a prosthetic eye is undiagnosed PTSD relating to the circumstances of one’s eye loss, which can make it hard to show up to medical appointments or try returning to activities that once gave one joy.

· What can you tell us about people’s experiences getting a scleral shell and people getting used to them over a damaged eye?

If the cornea has vascularized and no longer needs oxygen it is usually just a matter of time getting used to the sensation of wearing the shell. It should never be painful to wear the shell, but it may feel strange or uncomfortable initially. For patients who find it uncomfortable at first, I typically recommend starting with an hour or two per day and increasing the amount of time as that becomes tolerable.

Artist to ocularist. Painting that Andre has done that reflects her artistic skills that she uses to hand paint prothetic eyes.
Artist to Ocularist

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